Canada / Spain Agreement

Applying for a Spanish Old Age and/or Disability Benefit

Here is some important information you need to consider when completing your application. Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of a witness is required. Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application. Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you. You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy: Accountant; Chief of First Nations Band; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Pharmacist, Psychologist, Nurse Practitioner, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a reciprocal social security agreement; Police Officer; Postmaster; Professional Engineer; Social Worker; Teacher. People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document. They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way. If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you. Return your completed application, forms and supporting documents to: International Operations Service Canada P.O. Box 250 Fredericton, NB E3B 4Z6 CANADA

Disclaimer:

This application form has been developed by external sources in cooperation with Employment and Social Development Canada. The content and language contained in the form respond to the legislative needs of those external sources.

I CAN- E l 1

CONVENIO SOBRE SEGURIDAD SOCIAL ENTRE E S P A ~ A Y CANADA CONVENTION ON SOCIAL SECURITY BENVEEN SPAIN AND CANADA

CONVENTION DE S ~ C U R I T ~ SOCIALE ENTRE L'ESPAGNE ET LE CANADA

Vejez Old Age benefits Vieillesse

lnvalidez

SOLlClTUD DE PRESTACIONES CONFORME A LA LEGISLACI~N ESPA~~OLA POR (1) Disability benefits

CLAIM FOR BENEFITS UNDER SPANISH LEGISLATION (I) lnvalidite

DEMANDE DE PRESTATIONS EN VERTU DE LA LEGISLATION ESPAGNOLE POUR (I) Muerte Death benefits D6cBs

Supewivencia Survivor's benefits Survivants

Titulo Ill del Convenio / Part 111 of the Convention 1 Titre Ill de la Convention

Artlculos 6 y 7 del Acuerdo Administratlvo Articles 6 and 7 of the Administrative Agreement

Articles 6 et 7 de I1Arrangernent Adrninistratif

Losrecuad~~~ estdn resewados ai uso de la Administracldn canadlense Boxes are reserved for the Canadian Administration

Lescases sont rBservBes A Mdministration canadienne

A CUMPUMENTAR EN TODO CASO / TO BE COMPLETED IN ALL CASES / A REMPLlR DANS TOUS LES CAS

NGmero de Seguro social de Canadd Canadian Social Insurance Number NumBro d assurance sociale du Canada - 1

DATOS PERSONALES DEL ASEGURADO Y DE su CONYUGE PERSONAL INFORMATION REGARDING THE INSURED AND HIS/ HER SPOUSE RENSEIGNEMENTS PERSONNELS CONCERNANT LA PERSONNE ASSUR~E ET SON CONJOINT

1.1. Apellldos (4) Sumames (4)

Norns de farnille (4)

1.2. Apellldos de soltera Maiden name Norn de jeune fille

1.3. Nombre First name Prknorn

Del solicitante (2) Claimant (2)

Du dernandeur (2)

Del c6nyuge (3) Spouse (3)

Du conjoint (3)

1.4. Nombre de 10s padres Name of parents Nom des parents

1.5. Dlreccl6n (5) Address (5) Adresse (5)

1.6. Fecha de naclmlento Date of birth Date de naissance

1.7. Sex0 Sex Sexe

1 .a. Naclonalldad Citizenship Nationalit6

1.9. D. N. I. (6) Number of ldenffty Card (6) No. de carte d'identitb (6)

1.lO.No. de aflllacl6n a la Segurldad Social espaftola Spanish Social Security number No. d'affillation B la Sbcuritb Soclale espagnole

1.11.Estado clvil (7') Marital status (7) Etat civil (7)

1.12.Fecha de matrimonlo Date of marriage Date de mariage

1.13.Fecha de falleclmlento Date of death Date du dbds

1.14.Causa del falleclmlento (8) Cause of death (8) Cause du decks (8)

1.15. jSe considera el lnteresado lncapacitado para el trabajo? Does the daimant consider himlherself unfit for work? L'lntBressQ(e) se considhre-t-il (elle) inapte au travail?

1.16.~Reallza actlvldad laboral? Is he/she working at present? Travaille-1-11 (elle) encore?

1.17.~Esth acogldo a Convenlo Especial? Does claimant belong to a special plan (voluntary insurance)? BQnbficie-1-11 (elle) d'une convention spbcialel assurance volontaire?

1 .lB.Fecha en que ha dejado de trabajar Date on which employment ceased Date d'arret de travail

1.1O.Fecha en que se propone cesar Date on which employment is expected to k a s e Date pdvue d'arret de travail

1.20.~Percibe alguna prestaclbn? (9) Is any benefit paid? (9) Une prestation est-elle versbe? (9)

1.21 .LHa perclbldo alguna prestacl6n? Has any benefit been paid? Une prestation a-1-elle 616 vers&?

Del sollcitante (2) Claimant (2)

Du demandeur (2)

Del c6nyuge (3) Spouse (3

DU conjo~nt (3)

1.22. SI uno de 10s puntos 1.20 o 1.21., es aflrmatlvo, lndlcar if either 1.20 or 1.21. is a m a t i v e please state: Dans I'afflrrnative a 1.20 ou 1.21 ., indiquer:

Clase de pensl6n Type of pension Le type de pension

Organlsmo que la satisface Institution responsible for payment L'organisme responsable du paiement

lmporte mensuel (10) Monthly benefit (10) Le montant mensuel (10)

Fecha de efectos Date on which pension became payable La date du debut des paiements

Feche do venclmlento Date on Mich pension ceased or is expected to cease La date de cessation des paiements

1.23. Otros recursos Other resources Autres ressources connues

- 2

Del solicitante (2) Claimant (2)

Du demandeur (2)

A CUMPLIMENTAR I~NICAMENTE EN EL SUPUESTO DE SOLlClTUD DE PENSION DE INVALIDEZ TO BE COMPLETED ONLY WHEN CLAIMING A DISABILlN PENSION A REMPLIR UNIQUEMENT EN CAS D'UNE DEMANDE DE PENSION D'INVALIDIT~

Del conyuge (3) Spouse (3

Du conjo~nt (3)

ORIGEN DE LA INVALIDEZ I CAUSE OF DISABILIN 1 CAUSE DE L'INVALIDIT~

Enfermedad comun Enfennedad profeslonal Accldente de trabajo Accldente no laboral Common illness [7 Occupational disease industrial accident Non-industrial accident Maladie commune Maladie professionnelle Accident du travail Accident non pmfesslonnel

HlJOS I CHILDREN I ENFANTS

Apellldos y nombre

Sumames and First Name

Norns et Pr6noms

~ E s t d Inca- pacltado para el

trabajo?

Is he/she unfff lor

emp/opent?

Est-ll(elle) lnapte au travall?

Fecha de nacimlento

Date of bltih

Date de naissance

L E ~ penslonlsta o tltular

de re,,tn? Is he/she a

pensioner w recipient of a penodrc benefit?

Est-ll(elle) retralt6(e) ou

t~tulaire dune renle?

~Obtlene OtmYJ Ingm=3?

he/she Ofher

Income7

Re@t-ll(elle) d'autres revenus?

7

4 DECLARACION DE ACTIVIDADES DEL ASEGURADO EN E S P A ~ A EMPLOYMENT HISTORY OF THE INSURED IN SPAIN EMPLOIS PRECEDENTS DE L'ASSURE(E) EN ESPAGNE

- 5

PER~ODOS TRABAJADOS EN OTROS PA~SES PERIODS OF WORK IN OTHER COUNTRIES PERIODES TRAVAILLEES DANS D'AUTRES PAYS

Nornbre y dlrecci6n de la Ernpresa Name and address of employer Nom et adresse de I'employeur

Provlncia Province Province

Periodo (a Aos)

Desde Hasta

Period (years)

From To

Pdriode (ann6es)

De A

No. de asegurado o, en su defecto, nombre de la Empresa, trabajos corno autbnorno, etc.

Social Security Number or name of the enterprise, work as self-employed person, etc.

No. d'assurd ou, sinon, nom de I'Entreprise, activitds exerches en tant que le

travailleur independant, etc.

Periodo 1 Period 1 Pdriode

Localldad City

Localit6

desde 1 from 1 de

Pais Country

Pays

haste I to 1 8

Declaro, bajo ml responsabilidad, que son ciertos 10s datos que conslgno en el presente formulario. Asimismo, manlfiesto que quedo enterado de la obligaclon de comunlcar al lnstltuto Naclonal de Seguridad Social cualquier varlacion en 10s datos declarados que pueda producirse en lo sucesivo.

1 hereby declare that the information provided in this form is true and accurate. I further acknowledge that I am required to notify the INSS of any change in this information which may occur in future.

Je declare, sous ma responsabilite, que les reinseignernents que je fournis dans la presente forrnule sont vrais. De meme, je declare que je suis tenu de communiquer B I'lnstitut National de la S6curitB Sociale tout changernent relatif aux renseignements declares qui pounait intervenir dans I'avenir.

(A CUMPLIMENTAR S ~ L O EN CASO DE SOUCrrUO DE PRESTACIONES DE SUPERVNENCIA) (TO BE COMPLETED ONLY IN CASE OFA CLAIM FOR A SURVIVOR'S PENSION)

(A NE REMPLIR QU'EN CAS D'UNE DEMANDE DE PRESTATIONS DE SURVIVANT)

Declaro, bajo ml responsabilidad, que convlvfa con: I declare, under my responsibility, that I lived with: Je declare sur I'honneur, que je vivais avec: ............................................................................................

en el siguiente domlclllo: ..................................................................................................................................... at the following address: ................................................................................................................................... B l'adresse suivante: .....................................................................................................................................

desde 1 I I I hasta I I I I Die Mes AAo

from Day Month Year Die Mes AAo

d~ Jour Mois Ann& f0 Day Month Year a~ Jour Mois Ann&

Autorlzo a la Institucl6n de Canad6 a facllltar al lnstituto ~ac iona l de Seguridad Soclal de Espafia, toda la lnformacion y pruebas que posea, relacionados o posiblemente relacionados con esta solicitud de prestaciones.

I authorize the Canadian institution to provide the INSS with any information or evidence it may have which relates, or which might relate to the present claim for benefits.

J'autorise I'organisme canadien B fournir B I'lnstitut National de Sdcurite Sociale dlEspagne tous les renseignernents et preuves qu'il detient, et qui sont ou peuvent &re relatifs B la pr6sente dernande de prestations.

Firma del sollcltante, Claimant's signature,

Signature du demandeur,

A CUMPLIMENTAR POR LA INSTITUC~ON CANADIENSE TO BE COMPLETED BY THE CANADIAN INSTITUTION A REMPLIR PAR L'ORGANISME CANADIEN

Se hace constar que 10s datos personales vidados en este formularlo han sldo debidamente comprobados por esta Instltucion.

This certifies that the personal information supplied in this form has been duly verified by this Institution.

Ceci certifie que les renseignements personnels fournis dans la presente formule ont Bt6 dOment verifies par I'organisme.

Sello Fecha Stamp Da fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - Timbre Date

Flrma Signature Signature .......... ..................... . .. .......................... .. . .......... ..

NOTAS / NOTES / NOTES

Marquese lo que proceda Mark whichever is applicable Cocher la case appropriee

En las solicitudes de vejez e invalldez: 10s datos del prop10 Interesado. En las de viudedad, 10s correspondientes a la viudalo. En las de orfandad: 10s correspondientes a la viudalo o en su defect0 el representante legal de 10s huBrfanos. If old age or disability benefits are being claimed, provide information in this column regarding the insured person . If widow's/widower's benefits are being claimed, provide information in this column regarding the widowhidower. If orphans' benefits are being claimed, provide-information in this column regarding the widow/widower or, if there is none, regarding the legal representative of the orphaned child. Pour les demandes de prestations de vieillesse ou d'invalidite, donner les details concemant la personne assuree. Pour les demandes de pension de veuf (veuve), donner les details concernant le veuf/veuve.Pour les demandes de prestations d'orphelin, donner les details concernant le veuflveuve ou, s'il n'y en a pas, le representant legal de I'orphelin.

En las sollcitudes de vejez e invalidez: 10s datos del c6nyuge del asegurado. En las de supewlvencia: 10s del asegurado fallecido. If old age or disability benefits are being claimed, provide information in this column regarding the spouse ot ihe insured person. If survivors' benefits are being claimed, provide information in this column about the deceased insured person. Pour les demandes de prestations de vieillesse et d'invalidite, indiquer les donnees concemant le conjoint de la personne assuree. Pour les demandes de pension de survivant, indiquer les donnees concemant la personne assure6 de&d6e.

Para naclonales espafioles, conslgnar 10s dos apellldos. For Spanish nationals, list both surnames. Pour les ressortissants espagnols, indiquer les deux noms de famille.

NLirnero, calle, localidad, distrito postal, pais. Number, street, town, postal code, country. - .- . - Numero, rue, vilie, code postal, pays.

Para naclonales espaiioles, indicar el numero del Documento Naclonal de ldentidad (D. N. I. ), aunque estB caducado. Si no lo posee, indicar expresamente: "no tiene". For Spanish nationals, enter identity card (DNI) number even if expired. If claimant does not have a DNI number, enter the words "no identity card': Pour les ressortissants espagnols, indiquer le numero de la carte d'identite (D.N.I.) meme s'il n'est pas valable. S'il (elle) n'en a pas, indiquer "pas de carte d'identite".

lndlcar de entre Bstos el que proceda: soltero, casado, separado, divorclado, viudo y, a contlnuaclbn, desde cuando. State whether single, manied, separated, divorced or widowed (give date of separation or divorce, or date of spouse's death). lndiquer si la personne assuree est celibataire, mariee, separee, divorcee ou veuve 1 veuf (donner la date du divorce ou du decbs du conjoint).

lndlcar lo que proceda: accidente de trabajo, enfermedad profeslonal, accldente no laboral, enfermedad comun. State cause of death : industrial accident, occupational disease, non-industrial accident or common illness. lndiquer la cause du decbs: accident du travail, maladie professionnelle, accident non professionnel ou maladie commune.

Desempleo, lncapacldad laboral transitoria, invalidez provisional, etc. Unemployment, temporary incapacity, provisional disability, etc. Chamage, invalidit6 temporaire, invalidit6 provisoire, etc.

Pesetas o dolares canadienses. Indicate whether figure is in pesetas or Canadian dollars. lndiquer si le montant est en pesetas ou dollars canadiens.

DOCUlVLENTOS QUE DEBE PRESENTAR CON ESTA SOLICITUD DOCUMENTS TO BE SUBMITTED WITH THIS CLtUM

DOCUMENTS QUE vous DEVEZ PRESENTER AVEC LA DEMANDE

a) Solicltud de pensl6n de vejez: Application for old age pension: Dernande de pension de vieillesse: - Documento Naclonal de ldentldad o Certlflcacl6n de Naclmlento.

National ldentify Card or Birth certificate. Carte d'ldentit6 Nationale ou certificat de nalssance. - Si realizd trabajos en el sector maritimo - pesquero en Espaiia, aportah la libreta de Navegacidn espaflola y , en su caso, tambien la de 10s demhs paises donde haya realizado tal clase de actividad, o cualquier tip0 de docurnentacidn (certificados de ernpresa, de la Autoridad de Marina, etc ...) que acredite dichas circunstancias. If the insured person performed a professional activity in the merchant marine or fishlng industry in Spain, he / she should provlde the Spanish Navigation booklet and, where applicable, the booklets of other countries where such activity was performed, or any kind of documentary evidence ( certifica- tes Issued by a company, marine authorify, etc.) cerliwng such activities. SI des activites de pbche maritime ont 616 kalisees en Espagne, presenter le livret de Navigation espagnole, alnsl que celul des autres pays oi, ce type d-activit6 aurait 6te eventuellement realis6 ou toute autre documentation (certificat d'entreprise, de I' autorite maritlme, etc.) le certifiant.

b) Sollcltud de pensi6n de Invaiidez: Application for disability pension: Dernande de pension d'invalidite: - Documento Naclonal de ldentldad o Certlflcacldn de Naclmlento.

National ldentity Card or Birth certificate. Carte d'ldentit6 Nationale ou certificat de naissance. - Documentaclon medlca. Medical documents. Cerlificat rn6dical. - Si realizd trabajos en el sector marltimo - pesquero en Espaiia, aportad la llbreta de Navegacidn espaflola y , en su caso, tambien la de 10s demhs paises donde haya reaiizado tal clase de actividad, o cualquier tip0 de docurnentacidn (certificados de ernpresa, de la Autoridad de Marina, etc ...) que acredite dichas clrcunstanclas. If the insured person performed a professional activity in the merchant marine or fishlng industry in Spain, he / she should provide the Spanish Navigation booklet and, where applicable, the booklets of other countries where such activify was perfonned, or any kind of documentary evidence ( certifica- tes issued by a company, marine authority, etc.) certifying such activities. Si des activites de phche maritime ont Btd realisees en Espagne, presenter le livret de Navigation espagnole, alnsl que celui de? autres pays oh ce type d'activitd aurait Qt6 Bventuellement realist5 ou toute autre documentation (certificat d'entreprise, de I autorite maritime, etc.) le certifiant.

c) Sollcitud de prestacldn por muerte y supervlvencia: Application for sunriwr's benefits: Demande de prestations de su~ivants: - Si realizd trabajos en el sector marftlmo - pesquero en Espafla, aportad la libreta de Navegacldn espaflola y , en su caso, tamblen la

de ios dernhs paises donde haya reallzado tal clase de actividad, o cualquier tipo de docurnentacidn (certificados de empresa, de la Autoridad de Marina, etc ...) que acredite dichas circunstancias. I f the insured person performed a professional activity in the merchant marine or fishing industry In Spain, he /she should provide the Spanish Navigation booklet and, where applicable, the booklets of other countries where such activity was performed, or any kind of documentary evidence ( cerfifica- tes issued by a company, marine authority, etc.) certifjing such activities. Si des activites de peche maritime ont 616 kalisbes en Espagne, presenter le livret de Navigation espagnole, alnsl que celui des autres pays oi, ce type d'activltd aurait Bt6 eventuellement reallse ou toute autre documentation (certificat d'entreprise, de I' autorite maritlme, etc.) le certifiant.

En todo caso 1 In all cases / Dans tous les cas: - Certificacidn de defunclon, en la que se haga constar la causa del falleclmlento. Death certificate stating cause of death. Certificat de d6&s, avec mention de la cause du d6chs. Pensldn de vludedad: Su~ 'v ing spouse's penslon: Pension de veuf (veuve): - Documento Naclonal de Identidad o Certlficacldn de naclmlento de la vludehrludo.

National ldentify Card or Blrth certificate of the widowhvidower. Carte d'ldentitb Nationale ou certificat de naissance de la veuveheuf. - Llbro de Famllla o, en su defecto, certlflcaclon de matrlmonlo. Family Register of Vital Statistics or marriage certificate. Livret de farnille ou certificat de mariage. - En caso de exlstlr separacldn legal o dlvorclo, fotocopla de la sentencla flrme en que se acredite. SI no hublera sentencia flnne, fotocopla del documento que justiflque haber lnlclado el expediente de separacldn matrlmonlal o de dlvorclo. In the case of legal separation or divorce, attach a copy of the final decree or proof that separation or divorce proceedings have been initiated. En cas de separation legale ou de divorce, annexer une cople de la decision du' tribunal. S'il n'exlste aucune d6clsion, annexer une copie du document justiflant que la procedure de separation maritale ou de divorce a 616 entambe.

Pensldn de orfandad: Olphan's pension: Pension d'orphelin: - Llbro de famllla o, en su defecto, Documento Naclonal de ldentldad o Certlflcacldn de naclmlento de 10s hljos por 10s que

sollclta pensldn (menores de 18 aiios o mayores Incapacltados). De exlstlr hljos adoptlvos, documentos que acrediten la adopcidn legal. Family Register of Vital Statistics, National ldentity Card or Birfh certificates of children for whom benefits are being claimed (disabled adults or minor children under 18). In case of adopted children, provide proof of legal adoption. Livret de famille, Carte d'ldentitb Nationale ou certificat de naissance des enfants pour lesquels une penslon est demandbe (enfants de rnoins de 18 ans ou plus, s'ils sont incapables de travailler). En cas d'enfants adoptes , documents certifiant I'adoption i6gale.

Canada / Spanish Agreement

Documents and/or information required to support your application [CAN-E 1] for a Spanish Old Age and/or Disability Benefit

Complete the attached forms:

• Canadian Residence [SC ISP5013]

• Statutory Declaration of Cessation of Work

• Medical Report [CAN/E-4] (only if you are applying for a Spanish Disability pension) Original or certified documents to be submitted:

• Birth certificate or National Identity Card (D.N.I.)

• Marriage certificate (if applicable)

• Spanish Navigation booklet or documentary evidence certifying such activity (only if you performed professional activity in the merchant marine or fishing industry)

• Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as:

Immigration 1000, passport, visa, ship or airline tickets, etc.) Information required:

• Your Spanish National Identity Card (D.N.I.) Number: ____________________ • Your Spanish Social Security Registration Number: ____________________

IMPORTANT: If you have already submitted any of the documents required when you applied for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them.

PROTECTED B (when completed)

SC ISP-5013 (2012-10-12) E 1 of 2

Service Canada

Personal Information Bank HRSDC PPU 175

CANADIAN RESIDENCECanadian Social Insurance Number

Mr. Mrs.

Ms. Miss Given Name and Initial Family Name

The following information is required to support your application for benefits under a social security agreement. If required, please provide additional information on a separate sheet of paper.

1. If you were born outside of Canada, please provide us with the following information:

Date of arrival in Canada:

Place of arrival in Canada:

2. List all the places where you have lived in Canada after the age of 18 and provide proof of all your entries and departures (Permanent Resident card, Record of Landing (IMM 1000), complete passport, airline tickets, etc.):

From (Year/Month/Day)

To (Year/Month/Day) City Province/Territory

3. List all absences from Canada, which were longer than six months, during your Canadian residence listed in number 2 above:

Departure (Year/Month/Day)

Return (Year/Month/Day) Destination Reason

Service Canada delivers Human Resources and Skills Development Canada programs and services for the Government of Canada.

Disponible en français

PROTECTED B (when completed)

SC ISP-5013 (2012-10-12) E 2 of 2

Canadian Social Insurance Number

4. Please give us the names, addresses and telephone numbers of at least two people, not related to you by blood or marriage, who can confirm your Canadian residence:

Name Address City Telephone Number

DECLARATION OF APPLICANT

I declare that this information is true and complete.

NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.

Signature Date (Year Month Day)

Telephone number

X

STATUTORY DECLARATION OF CESSATION OF WORK DECLARATION STATUTMRE DE CESSATION DE TRAVAIL

DECLARACI~N DE CESE EN EL TRABAJO

I, Je, soussigni(e) yo,

(Name in full 1 Nom au complet 1 nobre cornpleto)

residing at rbidant ri domiciliado(a) en

(Number and street / Numiro et rue 1 N h e r o y calle)

in the city 1 town / village of dans la ville / le village de de la ciudad de

county of in the Province of dans la province de

condado de , de la provincia de

whose Spanish social security registration number is: don? le numiro d'immatriculation de la se'curiti sociale en Espagne est : con n b e r o de afiliacidn a la Seguridad Social espaiiola:

SOLEMNLY DECLARE, for the purposes of a claim for an Old Age Pension under the social security legislation of Spain, that I have ceased 1 will cease work on the date indicated below.

DECLARE SOLENNELLEMENT, auxjins d'une demande de prestation de vieillesse aux termes de la le'gislation de se'curite' sociale de l1Espagne1 que j 'ai cessi/je cesserai de travailler b la date indiquie ci-dessous.

DECLARO BAJO MI RESPONSABILIDAD, a efectos de solicitud de prestacidn de jubilacidn conforme a la legislacidn espaiiola de Seguridad Social, que he cesado / cesard de trabajar en la fecha que se indica a continuacidn.

6 Day Month Year

Jour Mois Annie Dia Mes Aiio

[CONTINUED ON REVERSEISUITEAU KYRSOICONTINUA AL DORSO]

Moreover, I ack&wledge my obligation to inform the Instituto Nacional de la Seguridad Social of any paid work which I may hereafter undertake.

En outre, je reconnais mon devoir d'aviser l1Instituto Nactional de la Seguridad Social en tout cas oil, h I'avenir, je m 'engagerais h efectuer un travail remunire'.

Asirnismo, manifiesto que quedo enterado de la obligaci6n de comunicar a1 Instituto Nacional de la Seguridad Social la realizaci6n de cualquier trabajo que inicie en le sucesivo.

I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath.

Je fais cette de'claration solennelle la croyant vraie en conscience et sachant qu'elle a la mCme valeur que si elle e'tait faite sous serment.

Hago esta declaraci6n creyendo en conciencia que es cierta y sabiendo que tiene el mismo valor que si la hubiera hecho bajo juramento.

Signature of declarant Signature du dkclarant Firma del declarante

This declaration must be signed before a commissioner of oaths who must complete the section below. If you bring this form to a Human Resource Centre of Canada, an officer who is a commissioner of oaths will provide this service without charge.

Cette de'claration doit Ctre signke devant un commissaire aux serments qui doit remplir la section suivante. Si vous retournez vous-mCme ce formulaire h un Centre des ressources humaines du Canada, un fonctionnaire quie est un commissaire a m serments vous fournira ce service gratuitement.

Declared before me at the city 1 town I village of De'clare' en ma pre'sence h la ville / ou village de Declar6 en mi presencia en la ciudad de

county of in the Province of comte' de dans la province de condado de , de la provincia de

this day of ce jour de este dia de

A commissioner of oaths Commissaire aux serments Empleado juridic0

(Signature / Firma) (Seal / Sceau I Sello)

CONVENIO DE SEGURlDAD SOCIAL ENTRE CANADA Y ESPANA 'CONVENTION ON SOCIAL SECURITY BETWEEN CANADA AND SPAIN

INFORME MEDICO

MEDICAL REPORT

A CUMPLIMENTAR POR EL ASEGURADO I SOLICITANTE : TO BE COMPLRED BY CONTRlBUTOR/APPLlCANT:

Numero del Seguro Social de Canada del asegurado la

Contributors Canadian Social Insurance Number ..............................................................................................................

Apellido del asegurado I a Nombre del esegurado l a ................................................. ..................................................... Contributors Family Name Contributor's Given Name

Domicilio ( N O , Calle, Apto.) /-/om0 Adress (NO., Street, Apt. NO.) .................................................................................................................................

Cludad, localidad o pueblo C6digo Postal Pals Cify, TownorVillage ..................................................... posta l~ode . ........................... Country ...............................

Nlimero teldfono (incluyendo el c6digo del area, de la ciudad, o de la regi6n) Telephone Nu-nber (including area, city or regional code ) ...................................................................................................

A CUMPLIMENTAR POR EL MEDICO : TO BE COMPLETED BY MEDICAL DOCTOR :

2. Diagn6stlco l s : Diagnosis (es) :

3. Historial medico anterior relevante I significative : Relevant /significant previous medical history :

1. Fecha de la primera consulta del entermo la : Date of patient's first visit :

t Dia Mes Ailo

Day Month Year

(So pusdo dlaponar de alte lormulario lgualmantc en fmncba)

(Cene lomule esI Bgalemenl dispon~ble en Iran@is)

Fecha de la ultima consulta del enferrno I a : Date of patient's last visit :

\ I I I I I I Dia Mes Ailo

Day Month Year

4. Hospitalizacldn : Nombres de 10s establecimientos, fechas aproximadas de hospltalizaci6n durante 10s dos ultimos atios, motivo I s del ingreso y tratamiento. Hospitalization : Names 01 institutions, approximate dates of hospitalization in the past /wo years, reason (s) for admission and treatment.

5. Altura : Peso : Tensicin arterial :

Height : Weight : Blood Pressure :

6. Obsewaciones y resultados del exemen cllnico m8s reciente : Senale todas las limitaciones tuncionalee que se puedan cuantificar. Observations and positive findings on most recent clinical examination : Please note any measurable functional limitalions.

7 . Opini6n del especialista al respecto, infonnes de laboratorio, rayos X, etc. : En caso de que se hayan adjuntado documentos, & desea que la sean devueltos 3 Relevant consultant opinions, laboratory reporls, X - rays, etc. : If you have included any enclosures, do you wish them returned ?

8. i Hay previatos otros exhmenes o exploraciones medicas ? En caso afirmativo, enumere su naturaleza, el lugar donde se llevarhn a cabo, cuando y por quihn. Are any future examinations or medical investigations planned ? If you said 'Yes', please list type, where, when and by whom.

9. Medicacidn actual : Enumere 10s medicamentos segljn el nornbre generic0 o comercial e indique la dosis y la trecuencia. Current medications : Please list by generic or trade name and indicate dosage and frequency.

10. Tratarniento : Exponga el tipo y la respuesta. Treatment : Please list type and response.

11. Resumen y Prognosis : Summary and Prognosis :

Nombre del mddico Medical Docfor's Name ...........................................................................................................................................

NO. de teldfono (incluyendo el c6digo del area, de la ciudad o de la regi6n). Telephone Number (including area, city or regional code). ...............................................................................................

Domicilio (No., Calle, Apto.). Home Address (No., Street, Ap1.No.J ............................................................................................................................

Cddlgo Postal Cludad, localidad o pueblo Pais Postal Code.. ................... City, Town or Village ................................................. Country ..............................................

Mddico de cabecera Especialidad, si la tuviera Family Physician Speciality, if any .....................................................................................................

l I nn ID3 Df a Men Aiio

DeY Month Year

Firrna Signature